Lean in Saskatchewan

Transforming health care, four and a half seconds at a time

Last month more than 700 people gathered in Saskatoon to take part in Health Care Quality Summit 2012. One of the highlights for me was the panel discussion — “Engaging Patients in Quality Improvement: Best Practices for Best Results” – moderated by Liz Crocker, Vice Chair for the Institute for Patient- and Family-Centred Care. Patient advisors and health care leaders from here in Saskatchewan shared personal stories about the benefits of truly listening to and working with the patients we serve. After an excellent discussion, Liz invited the audience to talk about their experiences and observations.

Bonnie Brossart, CEO of Saskatchewan’s Health Quality Council stepped to the microphone and shared an incredibly personal story about one of her children. Matthew has Abdominal Migraine Syndrome and intermittently needs to get medical care in our local children’s emergency room. (Paul Levy, our closing keynote speaker captured Bonnie and Matthew’s story on his blog). The impact of Matthew’s story on the audience was palpable. Bonnie challenged us to rethink what exceptional care means to our patients, giving us a simple, practical, yet meaningful way to define and measure exceptional care: ask each and every patient you meet, “Is there anything else I can do for you today?”

I spent the week following the Quality Summit as the doctor in charge for the St Paul’s ICU. It is part of our culture and routine in our ICUs to invite the family to join the multidisciplinary team at the patient’s bedside as we gather to review the patient’s status and make the plan for the day. We’ve worked hard to make the ICU a place where families feel welcome and comfortable. But we haven’t yet really standardized our approach to having family member present on rounds, nor have we measured the impact of this change on our patients, families, and staff. I decided to complete my own PDSA of the simple change Bonnie challenged us all to make:

Plan: For one week, at the end of each bedside round, ask the patient and/or the family “Is there anything else I can do for you today?”Do: Do and describe what happened. I chose the following measures: how much time asking and answering the question took, how many yes’s how many no’s and what additional questions and requests were asked.Study: Analyze the results and determine what you learnedAct: Adapt, adopt, or abandon the change based on what you learned. Then complete the cycle testing out another small change.

I didn’t use any fancy data collection tools. Just a pen and a piece of paper that I carried in my back pocket, along with some additional attention paid to the clock on the wall. And I wrote down the answers to my question, which I asked 87 times over the course of one week.

What did I discover? Asking “Is there anything else I can do for you today?” added an average of 4.5 seconds to the length of the time I spent rounding with each patient. The patient and/or the family said “no thank you” 86 times. I only got one “yes.” This was a request that we figure out a way for our patient to watch that evening’s NHL playoff game. I also smiled a big smile when I overheard two of the four residents working with me that week asking the same question of nurses, patients, and families when they were working at the patient’s bedside.

Asking this important question did not slow me or my team down. I did not get asked any difficult or awkward questions. I felt like I made a stronger connection with the patients and families in the ICU. And I liked that this simple question provided a sense of closure to the round while signaling to the patient and family that we truly were interested in helping and supporting them. But those are just my feelings. What I should have done was ask a sample of patients and families what they thought of me asking them that question. Maybe that will be my next PDSA. Because now I’m committed to carry on asking every patient or family: “Is there is anything else I can do for you today?”

Did you come away from this year’s Quality Summit with any new ideas? What have you been testing since the conference?

About Dr. Susan Shaw

Chair, Health Quality Council.

Department Head, Adult Critical Care, Saskatoon Health Region.

Susan is Physician Co-lead for the Saskatchewan Surgical Initiative and an Assistant Professor with the College of Medicine’s Department of Anesthesiology, Perioperative Medicine and Pain Management at the University of Saskatchewan. She returned home to Saskatchewan to practice critical care medicine and anesthesiology in Saskatoon after completing fellowship training at Stanford University Medical Center in California.

About Better

Technology is the way of the future in medicine and I think this would help everybody – physicians as well as patients!

Dr. Rossouw, Physician, Regina Qu'Appelle

I was encouraged by the electronic concept of providing documentation in the Emergency Department. As a patient advisor, it was a positive experience to work with actual patients to receive patient input and opinions into this process.

Bev Greenfield, patient, Regina Qu'Appelle

This will save us a lot of time spent searching for equipment so that we can focus more on patient care.

Amanda Dela Cruz , LPN, Regina Qu'Appelle

Ordering supplies is logical and simplified…. (This project) will prevent an abundance of supplies that are not used, (resulting in) cost savings.

Shawn Duddridge , RN, Prairie North

I was excited to be part of a much needed project. It was great to see Emergency Department physician engagement. This will be a great improvement for patient care!

Shona Lafreniere Health Records Staff, Regina Qu'Appelle

Looking forward to saving steps and freeing up some time for Resident interaction. Good to be able to document interactions

Connie Redekop, CCA, Cypress

The passion targeted to quality care for our patients demonstrated during this RPIW will lead to great results.

Kevin Kozan, patient, Regina Qu'Appelle

The addition of a mobile stock/linen cart for the CCA’s with adequate stock greatly reduces lost time and steps. Go Team! By adding this time back to their day it can be used for prompt documentation and quality interactions with Residents.

Seccora Mazur, CCA, Cypress

With now having questions to ask, there can be more one on one interactions. With the introduction of the white boards in the room, I can see what is going on as a family member and also see what they need.

Cathy Nault, patient, Cypress

22 Responses to “Transforming health care, four and a half seconds at a time”

I was in Regina yesterday doing a transplant assessment clinic. I see patients with kidney failure who are hoping to receive a kidney transplant and also the occasional potential kidney donor (the true heroes of our society).

Anyways, I used your ‘idea’ at the end of each of my patients visit. All, like your experience, replied “no”. Maybe because prior to this I usually ask them if they have any questions and if they understand what we just discussed. But, going back to Kishore’s comment, all the patients did seem to have that look of “complete satisfaction”. Not only that, but selfishly I also felt satisfied….almost a sense of fulfillment that I was trying to do my job as good as I could! Can’t say that I have felt that too many times, not to mention 10 times in one day!

Replication of the experiment with replication of the results – very exciting! Thanks so much for sharing your experience, Rahul!

I’m glad that you, too, got that warm, fuzzy feeling about your work just by double-checking that you had met the needs of your patient. Its great that as we try to improve the care of our patients, we feel better about the work we do. Nice side-effect of doing the right thing!

As a family physician, I routinely ask my patients this, but honestly, it costs me a LOT of time. A lot more than 4.5 seconds. The ICU is a very different world. In the community, when you ask this kind of question, you get a LOT of questions back. Things that do need to be dealt with but often so many that they cannot possibly be dealt with in one visit. It needs to be asked, but to imply that all it takes is “4.5 seconds” is definitely not the reality for community based physicians. Care does need to be complete. Patients do need to have ample opportunities to raise questions or concerns, but doctors also need to see other patients and, gasp, make a living. Just keeping it real.

Thanks for your comments and observations on asking this question in your practice, which I imagine is quite different from mine both in structure and perhaps care model. My acute care practice is episodic: I work in seven-day blocks as part of a rotating team of intensivists. There is also likely a difference in resources and supports available to both me and my patients: I practice in a team-based approach with nurses, therapists, social workers, pharmacists and dieticians all meeting at the bedside as part of our daily rounds. This could be very different from how most patients receive their primary, community-based care. But I do think there is a lot in common between acute-care and community-based care: we all look after people in need, we all want to feel like we have done a good job in the eyes of our patients, and we are all being challenged to adopt more patient-centred philosophies. We likely have many more things in common than we realize.

As I’ve written in some of my replies to other comments, some “no” answers could very well be because I have not built a strong relationship with my patient or family where they feel safe making additional requests or asking more questions. Or maybe I just got lucky and didn’t get asked any tough questions during my week of measurement. I keep asking my question in my ICU practice and have yet to get asked a question that was difficult to answer or address either in subject-matter or time required to address it.

Your comment that doctors have to make a living is interesting. I think a fee for service payment model is one of the structural barriers we need to be willing to at least examine as we look at aligning incentives with the goals of our healthcare system: Better Care, Better Health, Better Value and Better Teams.

Dr Shaw’s post has been on my mind since it first appeared. My reaction was and remains positive…it is hard not to applaud simple and effective interventions. At risk of sounding negative there is also an element of the story that nags at me…not so much in what Dr Shaw relates but more generally in our current interest in customer service and patient-centered care. After reading Dr Shaw’s post I thought about my experience with exceptional service or care…in every instance the defining feature was the unexpected anticipation of my needs, service beyond my expectations and/or unfeigned interest in my needs. In the context of health care I’ve had many experiences with superb technical care but only a few exceptional experiences…one with a GP in Saskatoon who seemed deeply interested in any health concern I might have…the second with a cardiac surgeon who kept me waiting 30 minutes but promptly (and without prompting) apologized and told me I was his last appointment of the day and I could have as much of his time as needed to address my questions…and, finally, the anesthetist who ‘dropped by’ 24 hours after surgery for no reason but to tell me I had a valve repair as close to perfection as any he had ever seen. I don’t know what motivated the physicians in the above instances…but to me it felt entirely unscripted. And therein lies my concern with some of the interest in customer service and patient-centered care. In my opinion there is some risk that the delivery of exceptional care is confused with scripts and formulas…I think the latter can deliver superb technical care but I am less certain about their ability to tip the scales in favour of exceptional care. Health care providers are not mind-readers so Dr Shaw’s ‘question’ is incredibly important but if there is any magic in the question it is undoubtedly a reflection of the motivation and presence she brings to the asking of the question.

Hello Mr Murtagh. Thank you for your thoughtful comments. My primary goal for writing about my experience was to try to provoke some thinking, and I appreciate you sharing your reflections on your personal experiences.

Patients can certainly tell when a healthcare provider is not truly interested or concerned just as we can tell when anyone else in a service industry (yes that includes healthcare) is just going through the motions. Scripting might be useful as a prompt or a starting point but I doubt there would be any real positive impact for either parties to the conversation unless the person asking the question really wants to listen to the patient’s answer.

I hope I make my patients and their families feel comfortable and able to answer honestly. You are right, we are not mind readers, and despite all the technological advances in healthcare such as cardiac surgery, we should not forget that often it’s the human connections (both positive and not-so-positive) that we make with our patients that can have unmeasurable longterm impacts.

Hi Susan. First, I think the HQC needs to convene a high–level international ethics panel to determine whether you have committed a violation in outing your dad, who is anonymous no more.

But seriously, another factor involved in the “is there anything else I can do for you today” process is self-selection. Those personally motivated to asking the question are probably the high performers who are attentive to patients’ needs, and therefore likely to elicit a “no” response most of the time. It’s the usual Catch-22 in health care: the early adopters and conscientious, patient-centred providers are the first to board the improvement train, while those who really need a major tune-up aren’t even at the awareness stage.

None of this in any way detracts from your widely acknowledged awesomeness of course. In fact I’m sure many of the 87 patients in your mini-project said, “why, no thank you Dr. Shaw, but is there anything else I can do for you today – can I follow your orders more diligently, should I read up on the latest clinical findings relevant to my condition? I really want to be an ideal provider-centred patient!”

Steven, you are right. Just as in perhaps any other field of work, doctors and other healthcare providers exist on all over Rogers’ diffusion curve. And we do self-select which changes we are willing to try. The challenge (and where we offen fail) is the spread across the system.

You’ll likely agree that unfortunately we’ve spent years creating “provider-centered patients.” I think it’s likely a proportion of my “no” responses stem from years of not being meaningfully asked to contribute, question, or even challenge the doctor. But I remain hopeful that at least some “no” responses are because my team and I were already meeting their needs.

I agree with your thought that families/patients may not be asking for something further for reasons other than complete satisfaction. They may have been surprised by your question and not had time to consider their unmet need. They may not know what you have in your power to provide. They may not want to seem ungrateful for the care they are receiving by pointing out an unmet need.

Perhaps, next time you’re on service, your patients’ families could receive a card indicating that they will be offered the chance to voice unmet needs and so give them time to prepare (AKA next PDSA)?

That’s the beauty of this type of clinical thinking/research (Model for Improvement) – it always raises more questions, and has a mechanism to ge the answers quickly.

You don’t think my Dad, aka Anonymous, is completely correct when he offers an interpretation of 86/87 “no’s” as proof that his little girl is doing an awesome job?

Kidding aside, I think there are a multitude of possible explanations for my results. Interestingly to me, some patients and families were asked the same question 7 times (at least) over the course of my week of service. I didn’t observe any change in response even though we made a stronger connection and shared understanding as the week passed. The single request I got was from a “first time” patient who I hadn’t met before. Culture, style, and confidence on both the part of the patient/family and the physician/ICU all factor in to our daily interactions.

I like your suggestion to study the impact of standardized prep work of the patient and family. I’ve also received a suggestion from Bonnie Brossart to re-phrase the question to “Is there anything else I can do for you today? I have time.” I’m taking all these ideas under consideration. Stay tuned, maybe even subscribe, to the HQC blog to see what my next PDSA reveals.

Difficult to devise an objective measurement of effectiveness or effect of asking the question!
But it has probably occurred to you that monitoring the responses to the question does provide a potential measure of the family or patient’s assessment of the quality and value of their interaction with the team and the care they are receiving. I suspect that 86 “no” answers indicates that the family or patient feels they are being dealt with pretty well. A trend in the number of “no” answers over time would indicate a change in performance. A significant variation between responses to different practitioners or teams asking the same question would be an indication that an improvement is possible.

Something I have waited many years to hear from my long line of physicians involved in my care. It is strong leaders like you in the SHR who really understand what the patient needs will inspire a new wave of physicians the ability to treat patients the way they deserve.

Yesterday I did a Releasing Time to Care Pyramid visit on Unit 5B at St. Paul’s Hospital. The RTC team leader, Ashley Carter, explained the work she and her colleagues are doing on developing standard work for evening ward rounds. Ashley had attended and been inspired by the provincial Quality Summit, where Bonnie Brossart shared a very personal and powerful story about her son Matthew. Inspired by Bonnie and Matthew’s experience in one of our Emergency Departments, Ashley has worked with her team to include the following question as part of ward rounds
” Is there anything else that I can do for you?”. The RTC whiteboard lists examples of things that may question may involve, such as managing pain, toileting, mouth care or repositioning. I was very impressed by how one story has been a source of inspiration for providing more patient-centred care. It will be interested to see how this practice change is implemented by our staff and is received by our patients. Hopefully we can make this question standard work on every unit, for every patient, every day.

Thanks Maura for sharing more evidence about the power of stories. Stories engage the heart and move us to action. Hearing the many great stories told at the Quality Summit inspired me to change my clinical practice as I described in today’s post. But it also pushed me to increase the amount of storytelling (and storylistening) I do as I work to encourage others to think about changing the way they practice.

Your PDSA proved to me a very effective tool for dispelling the fear among providers that they will be swamped with impossible demands and expectations from patients and families if they dare to ask “Is there anythig ealse I can do for you?’

For as long as I remember, I’ve always asked the bedside nurse if there was anything else I could do for him or her before moving on to round with the next patient and nurse. But I have to admit I was a bit nervous that this question would add time or lead to difficult questions that were awkward to answer the first few times I asked it of my patients and their families. Maybe I got the results I did because patients and families are uncomfortable being asked this question so they defaulted to a “no thank you.” Perhaps with time, patients and families will start voicing needs and questions that otherwise wouldn’t be heard. But isn’t that the point: to find out what worries they have been keeping inside, or what they really need from us?

Thanks, Dr Goldman! I’d love to talk further about what I’ve personally learned and all the bemefits we gain across the system when we truly start to listen and learn from our patients and families. Looking back, i think I’ve learned more core lessons from patients than from my more traditional mentors, texts and journals.

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